Detox Intake Form



Detox Health Intake Form

Your time, thoughtfulness, and honesty are greatly appreciated.

Thank-you for your interest in this detox & wellness retreat. Please complete this form, even if you have submitted one for previous programs. The nature of your responses to the following questions will go a long way in assisting my understanding of your life & health, and will help me tailor the week to your specific needs.

Please read the forms carefully, sign, and return them as soon as possible by:

Mail:

Omega Institute for Holistic Studies

Attn: Registration Dept

150 Lake Drive

Rhinebeck, NY 12572

Or scan and email:

classapplications@

Please note that because our cleansing program is educational & experiential in nature, it is not intended as therapy for serious illness, nor a substitution for primary medical care.

Also, If you consume caffeine, nicotine, and/or artificial sweeteners regularly, I highly recommend that you reduce and/or wean yourself off them the week before you come, if possible.

GENERAL INFORMATION

Name:____________________________________________________________

Address:___________________________________________________________

City:_____________________________________ State:______________Zip:___________________

Phone: Home:______________________Cell: ___________________________

Email Address:______________________________________________________

Occupation________________________________________

Hours per week_________ Retired_____________________

Height____________ Weight__________________________

Has any other family member already been a patient?____________________

or attended a workshop of Dr. Tom? _______________________________

___Married___Partnership____Separated___Divorced____Widowed___Single

Live with:___Spouse___Partner___Parents ___Children ___Friends ____Alone

Do you have any children? Yes No How many? ________

Have you ever consulted with a Naturopathic Physician before? Yes No

What is the primary reason for your interest in this retreat?

______________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________

What would you like to accomplish with this program?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are your most important health concerns at this time?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did these issues/conditions develop?

Are there any traumatic events that you can identify as having caused or clearly aggravated your health challenges? What happened in your life around this time? Do you know anything about your birth process? If you prefer, list these in order of occurrence on a separate page

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Please list any prescriptions, medications, and supplements which you are presently taking and why?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever undertaken a cleanse before? _____yes _____no

If yes, for how long?_________________________________________________

Are you having regular bowel movements? _____yes ______ no

How many per day?_________ Well formed? _______________________

Easily eliminated? __________________________________________________

How would you rate your energy level? excellent good mediocre poor

How is your sleep? fall asleep easily? stay asleep throughout night? wake feeling refreshed?__________________________________________________________________

How would you rate your mood? ___excellent ___good ____average____poor

How would you rate your pain level? 0 (none) to 10 (extreme)_____________

DIET:

How is your appetite? ____extreme ____strong ____good ___lacking

What do you crave? _____carbs ____sugar _____salt _____meat ____ choc

other?________________________________________________________

How many meals do you generally eat each day? ___1 ___2 ____3 ____3+

Do you: ___eat out often ___diet frequently ___skip meals frequently

Do you have any special diet or eating restrictions? ____Yes ___No

if yes, please explain________________________________________________

List the primary foods you include in your diet

__________________________________________________________________

List the foods you exclude from your diet at this time______________________________________________________________

Do you have any food sensitivities that you are aware of? ______no _____yes

If yes, what foods?___________________________________________________

Do you currently experience food binges? ______no ______yes

If yes, what are the trigger foods?______________________________________

Are you currently using coffee, diet sodas, or nicotine? _____no ______ yes

If yes, how much daily?__________________________________________________________________

Mark those that you consume regularly:

____Caffeinated teas ___Artificial sweeteners ____Processed foods ____Preservatives ___Refined foods ____Margarine

___Trans-fatty acids ___Sugar/sweets

PAST MEDICAL HISTORY

YOUR PRENATAL/BIRTH PROCESS:

Any known problems/birth trauma during your mother’s pregnancy with you:_______________________________________________________________

C-section?________ Umbilical cord problems?_______forceps used?_______ Antibiotics?________ Breast fed?________ how long?______ Formula (kind):________________________how long?_______

Age solid foods began:_________

What foods were eaten in your first year of life___________________________

PERSONAL:

Major accidents/traumas (with dates):__________________________________

Severe stresses/emotional traumas:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you happy in your job or career? ____Yes ____No __________________________________________________________________

What personal goals do you have?________________________________________________________________________________________________________________________________

What makes you happy?_______________________________________________________________________________________________________________________________

What are you grateful for?___________________________________________

What is your individual & unique purpose in this life?_________________________________________________________________________________________________________________________________

What would you like to change most about your life?_________________________________________________________________________________________________________________________________

What behaviors, habits, or thoughts would you like to eliminate?____________________________________________________________________________________________________________________________

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